<?php $this->load->helper("form");?>
<div id="list">
<form method="post" action="<?php echo site_url("registration/register")?>" onsubmit="return Send(this)">
	<table class="form">
		<tr>
			<td colspan="2"><h4>Personal Details:</h4></td>
		</tr>
		<tr>
			<td><label>Title:</label><sup class="required">*</sup></td>
			<td><?php echo form_dropdown("title", $title_options, $item->title, 'class="width170px"')?></td>
			
		</tr>
		<tr>
			<td><label>Surname:</label></td>
			<td><input type="text" class="width170px"	name="surname" value="<?php echo $item->surname?>"  /></td>
		</tr>
		<tr>
			<td><label>First Name:</label><sup class="required">*</sup></td>
			<td><input type="text" class="width170px"	name="firstname" value="<?php echo $item->firstname?>" /></td>
		</tr>
		<tr>
			<td><label>Middle Name:</label></td>
			<td><input type="text" class="width170px"	name="middlename" value="<?php echo $item->middlename?>"  /></td>
		</tr>
		<tr>
			<td colspan="2"><h4>Contact Details:</h4></td>
		</tr>
		<tr>
			<td><label>Address:</label><sup class="required">*</sup></td>
			<td><textarea name="address"><?php echo $item->firstname?></textarea></td>
		</tr>
		<tr>
			<td><label>City:</label><sup class="required">*</sup></td>
			<td><input type="text" class="width170px"	name="city" value="<?php echo $item->city?>" /></td>
		</tr>
		<tr>
			<td><label>State:</label><sup class="required">*</sup></td>
			<td><input type="text" class="width170px"	name="state" value="<?php echo $item->state?>" /></td>
		</tr>
		<tr>
			<td><label>Country:</label><sup class="required">*</sup></td>
			<td><?php echo form_dropdown("country", $countries, $item->country, 'class="width170px"')?></td>
		</tr>
		<tr>
			<td><label>Telphone Number:</label><sup class="required">*</sup></td>
			<td><input type="text" class="width170px"	name="phone" value="<?php echo $item->phone?>" /></td>
		</tr>
		<tr>
			<td><label>Mobile:</label></td>
			<td><input type="text" class="width170px"	name="cellphone" value="<?php echo $item->cellphone?>"  /></td>
		</tr>
		<tr>
			<td><label>Email:</label><sup class="required">*</sup></td>
			<td><input type="text" class="width170px"	name="email" value="<?php echo $item->email?>" /></td>
		</tr>

		<tr>
			<td colspan="2"><h4>Account Details:</h4></td>
		</tr>
		<tr>
			<td><label>Username:</label><sup class="required">*</sup></td>
			<td><input type="text" name="username" class="width170px" /></td>
		</tr>
		<tr>
			<td><label>Passowrd:</label><sup class="required">*</sup></td>
			<td><input type="password" name="pwd" class="width170px"/></td>
		</tr>
        <tr>
			<td><label>Re-type password:</label><sup class="required">*</sup></td>
			<td><input type="password" name="re_pwd" class="width170px"/></td>
		</tr>
		<tr>
			<td></td>
			<td>
				<span class="leftSection">
					<span class="rightSection">
						<span class="middleSection"><input type="submit" value="Register" class="extendableBtn"></span>
					</span>
                </span>			
			</td>
		</tr>
	</table>	
</form>
</div>
